Current opinion in critical care
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Our understanding of critical illness is transforming as we develop a better understanding of the impact pathogen-associated molecular patterns and damage-associated molecular patterns (DAMPs) have on the pathogenesis of disease. Of the known DAMPs, there is a growing interest in mitochondrial DNA (mtDNA) as a DAMP capable of propagating the inflammatory response seen in sepsis and other conditions. In this review, we describe the varying mechanisms by which mtDNA is translocated from mitochondria into cytosol and the extracellular space where it can illicit an inflammatory response. In addition, we present some of the most recent clinical studies to examine mtDNA in critical illness. ⋯ Although mtDNA is a DAMP shown to be elevated in numerous conditions, the clinical ramifications of this finding remain elusive. Further work is needed to determine if mtDNA can be utilized as a biomarker of disease severity or mortality.
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Curr Opin Crit Care · Aug 2017
ReviewCritical care ultrasonography as complementary variable in the diagnosis and management of circulatory shock.
The objective was to define the role of ultrasound in the diagnosis and the management of circulatory shock by critical appraisal of the literature. ⋯ Use of ultrasonography for hemodynamic monitoring in critical care expands, probably because of absence of procedure-related adverse events. Easy applicability and the capacity of distinguishing different types of shock add to its increasing role, further supported by consensus statements promoting ultrasound as the preferred tool for diagnostics in circulatory shock.
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In the acute setting of circulatory shock, physicians largely depend on clinical examination and basic laboratory values. The daily use of clinical examination for diagnostic purposes contrasts sharp with the limited number of studies. We aim to provide an overview of the diagnostic accuracy of clinical examination in estimating circulatory shock reflected by an inadequate cardiac output (CO). ⋯ Single variables obtained by clinical examination should not be used when estimating CO. Physician's educated guesses of CO based on unstructured clinical examination are like the 'flip of a coin'. Structured clinical examination based on combined clinical signs shows the best accuracy. Future studies should focus on using a combination of signs in an unselected population, eventually to educate physicians in estimating CO by using predefined clinical profiles.
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To describe personalized hemodynamic management of critically ill patients in the operating room and the ICU. ⋯ Personalized hemodynamic management targets personal normal values of hemodynamic variables, which are adjusted to biometric data and adapted to the clinical situation (i.e., adequate values). This approach optimizes cardiovascular dynamics based on the patient's personal hemodynamic profile.
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The review aims to discuss emerging evidence in the field of microbiome-dependent roles in host defense during critical illness with a focus on lung, kidney, and brain inflammation. ⋯ In health, a diverse microbiome might enhance host defense, while during critical illness, the dysbiotic microbiome might contribute to comorbidity and organ dysfunction. Future research should be aimed at further establishing the causes and consequences of dysbiosis seen in the critically ill, which will provide perspective for developing new strategies of intervention.